POS0808 CHARACTERISTICS AND PROGNOSIS OF BINOCULAR DIPLOPIA IN PATIENTS WITH GIANT CELL ARTERITIS
Authors: T. Chazal, T. Sene, G. Clavel Refregiers, T. Leturcq, C. Bouche, A. Lecler, C. Vignal-Clermont
Journal: Annals of the Rheumatic Diseases (2022)

Background Giant cell arteritis (GCA) is a large vessel vasculitis associated with a risk of permanent ophthalmologic complications. Diplopia is an uncommon feature at GCA diagnosis and data about diplopia in GCA are scarce, especially regarding its prognosis. Objectives This study was designed to better characterize diplopia in newly diagnosed GCA patients. Methods All consecutive patients diagnosed with GCA between January 2015 and April 2021 in a French tertiary ophthalmologic center were retrospectively reviewed. GCA diagnosis relied on 1990 ACR criteria and either a positive temporal artery biopsy or high-definition MRI. Results Among 111 patients diagnosed with GCA in our tertiary eye-care center, 80 patients (72%) had visual signs, including 30 patients (27%) with binocular diplopia. Characteristics of patients with diplopia were similar to other GCA patients. Twenty-eight patients (93%) had cephalic symptoms (Headaches n = 25, scalp tenderness n = 14, jaw claudication n = 17) and 7 patients (23%) had associated polymyalgia rheumatica. All patients with diplopia had an elevated C-reactive protein compared with 91% of patients without diplopia (p = 0.06). Large vessel involvement was found in 4 patients (16%) with diplopia. Diplopia was attributed to cranial nerve palsy in 21/24 (88%) patients, especially third (50%) and sixth cranial nerve (48%) palsies. Median duration of diplopia before GCA diagnosis was 10 days (Inter-quartile range [IQR]: 4-19). Eleven patients (37%) were diagnosed with ocular ischemic lesions, including 5 patients (17%) with bilateral visual impairment, resulting in a severe loss of vision in 9 patients and a resolution of binocular diplopia in all these patients due to unilateral or bilateral vision loss. Acute ischemic optic neuropathy (AION) was diagnosed in 11 eyes, central retinal artery occlusion (CRAO) in 4 eyes and paracentral acute middle maculopathy in 2 eyes. Diplopia resolved spontaneously in 6 patients (20%). In the remaining 13 patients, diplopia resolved after the initiation of corticosteroids in 12 patients (92%) with a median delay of 10 days (IQR: 5-24). IV corticosteroids seemed to be associated with a quicker improvement than oral corticosteroids (6 days [IQR 4-28] vs 11 days [IQR 6-13], p = 0.81) but with a similar resolution rate of diplopia at one month (66% vs 78 %, p = 1). Two patients had visual impairment after the initiation of corticosteroids and two patients had diplopia relapse during the course of GCA. Conclusion Diplopia is a rare but not exceptional feature at GCA diagnosis and should raise clinician suspicion for GCA when associated with cephalic symptoms and elevated inflammatory biomarkers. We confirmed in this study that patients with diplopia were also at risk of ischemic ocular lesions, particularly AION and CRAO, with a subsequent risk of severe loss of vision. In patients without visual impairment, the prognosis of diplopia is good after initiation of treatment with a complete resolution in most patients at one month but with a potential risk of diplopia recurrence in case of GCA relapse. Disclosure of Interests None declared